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Monthly Pre-hospital Care Meeting

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Head Injury PHC - PowerPoint PPT Presentation


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NHS. Monthly Pre-hospital Care Meeting. Welcome. 25 th January 2008. NHS. Hosted by Pre-Hospital Care ( www.pre-hospitalcare.co.uk ) and Essex Police Sponsored…… Multi-disciplinary Open forum Sharing, developing and learning CPD Range of activities – open to suggestions

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slide1

NHS

Monthly Pre-hospital Care Meeting

Welcome

25th January 2008

slide2

NHS

  • Hosted by Pre-Hospital Care (www.pre-hospitalcare.co.uk) and Essex Police
  • Sponsored……
  • Multi-disciplinary
  • Open forum
  • Sharing, developing and learning
  • CPD
  • Range of activities – open to suggestions
  • Linked to international PHC projects
  • Networking
slide3

NHS

  • Themed evenings
  • Keynote lecture (30 – 40 minutes)
  • Short lecture (10-15 minutes)
  • Case Review with discussion
  • Literature / Journal Review
  • Guidelines / practice update
  • Practical demonstration / sessions
slide5

So you’re not an anaesthetist…..

How do you manage head injuries

at scene?

Dr Aaron Pennell MBBS MSc

Medical Advisor to Tactical Firearms Group

Essex Police

slide6

Objectives

  • Review the aetiology and pathology of brain injury
  • Understand the basis for current treatments
  • To review the current situation and recommendations
  • To discuss other options of managing brain injuries
  • To discuss how this may change in the future
slide7

Aetiology and Pathology

  • Around a million brain injuries a year in the UK
    • 150 000 minor, unconscious for < 15 mins, recovery in 3-6 months
    • 10 000 moderate, unconscious for up to 6 hours, some long term sequlae
    • 11 000 severe, unconscious for > 6 hours, 4500 will need long term care
    • and only around 15% will return to work within 5 years
  • More than 120 000 people in the UK are currently suffering from the long term
  • effects of a brain injury
  • Around 2500 brain injuries a day in the UK

Source: http://www.headwayessex.org.uk/facts/statistics.html

slide13

Aetiology and Pathology

Causes of Brain Damage

Contusion

Haematoma

Hypoxia

Diffuse

Axonal

Injury

slide21

Aetiology and Pathology

Hypoxia and ischemia

  • Permanent damage to neurones occur after a few minutes if perfusion
  • falls below a critical threshold
  • Brain looses its capability to autoregulate in head injury and is particularly
  • vulnerable to hypoxia and ischemia
  • Reduction in MAP (<60mmHg) especially with > ICP causes acute damage
  • Brain injury causing unconsciousness causes early respiratory deterioration
  • and bradycardia and is a sinister cause of ischemic damage
slide22

Management

MAP

CPP

HYPOXIA

slide23

Management

  • Early airway maintenance
  • Early stabilisation of gas exchange
  • Restoring and maintaining a functional perfusion pressure
  • Minimising raising intracranial pressure
  • RSI and Controlled ventilation
  • Volume & perfusion management
  • Pharmacological manipulation
slide24

Management

  • Rapid Sequence Induction (of anaesthesia)
  • Facilitates endotracheal Intubation in those with a GCS > 3
  • Permits controlled ventilation
    • Maximising oxygenation
    • Minimising increased ETC02
  • Currently a ‘doctor only’ skill in the UK
  • Also
    • Seizure control
    • Agitation control
    • Makes management more controlled
slide25

Management

  • Alternatives to RSI:
  • Effective airway control
    • LMA, OPA, NPA X2
    • High flow (15lpm) 02 +/- ventilatory support
  • Use of benzodiazepines / opiates …….(Diazepam, Midazolam, Morphine etc)
    • May be beneficial for the severely agitated patient
    • Can have undesired haemodynamic effects if used in sufficient doses to
    • try and create a ‘psuedo – RSI’
    • Respiratory depression – not a problem – allows for better ventilation – IF
    • YOU CAN MANAGE THE AIRWAY
    • Hypotension – will be detrimental if already a > ICP – but can use fluids to
    • maintain SBP ~ 80-90mmHg
    • This is probably a useful alternative for the non RSI trained practitioner IF
    • THEY HAVE THE AIRWAY AND VENTILATION SKILLS
slide26

Management

  • Establishing and maintaining a functional perfusion pressure:
  • IV access
  • Current (sensible) debates on what type of fluid is best
    • Hypertonic saline
    • Normal Saline
  • Aim to maintain SBP of 90-100mmHg
  • Hypotension is bad !
  • Cooper DJet al (2004)Prehospital hypertonic saline resuscitation of patients with hypotension
  • and severe traumatic brain injury: a randomized controlled trial. JAMA. 2004 Mar 17;291(11):1350-7.
  • Lenartova L et al (2007) Severe traumatic brain injury in Austria III: prehospital status and treatment
  • Wien Klin Wochenschr. Feb;119(1-2):35-45. Links
  • Myburgh J et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury (2007)
  • N Engl J Med. Aug 30;357(9):874-84
slide27

Management

  • Pharmacological Adjuncts
  • Mannitol – NO
  • Frusemide - Maybe
  • Steriods – NO
  • Antibiotics – Maybe (meningococcal disease)
  • Vasoactive agents – Maybe in ICU
  • Seizures
    • Treat with benzodiazepine
      • Do not get fraught over resp depression – ventilate !!!
slide28

Summary

  • Major head injuries are a challenge pre-hospital
  • While anaesthetic skills are perhaps ‘gold standard’ this DOES NOT
  • preclude the delivery of other quality interventions
  • Airway management and maximising oxygenation/ventilation
  • Use of opiates and benzodiazepines for the difficult to manage agitated
  • head injury (rememeer the caveats for this)
  • Maintaining a functional perfusion pressure
  • Treatment of seizures
  • Triage to an appropriate centre
slide30

Open Discussion

“Should ambulance paramedics be taught RSI”

slide31

Journal Review:

Strote J, Range Huston H (2006) Taser use in restraint related deaths

Pre Hospital Emergency Care. 10:4 447-450

slide32

Case series of TASER related deaths – convenience sample

  • 2001 – 2005
  • Identified through internet search – PM reports requested
  • Analysed for
    • Demographics
    • Pre-existing cardiac disease
    • Toxicology
    • Evidence of excitable delirium
    • Restraint techniques used
    • Listed cause of delirium
slide33

75 cases identified

  • 37 PM reports available
  • All male 18 – 50 years
  • CV disease found in 54.1%
  • Toxicology for illicit drugs found in 75.7%
  • TASER considered a contributory case of death in 27%
  • Cause of death:
  • Intoxication/stimulant 18 (48.6%)
  • Cardiac Arrest/arrhythmia 12 (32.4%)
  • Excitable delirium 3 (11.1%)
  • Positional Asphyxia 2 (5.4%)
  • CCF 1 (2.7%)
  • Undtermined 1 (2.7%)
slide34

Discussion

  • Used standard search engines to seek data!
  • Role of:
    • a) Restraint techniques
    • b) Toxicology
    • c) Pre-existing disease
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